MEDICARE: KARL MATTHEW NETTLES JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	M9538	TX
2	2085R0202X	Diagnostic Radiology Physician	MD.207260	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BP1-0026378	OTHER		INSTITUTIONAL PERMIT

General Provider Information

NPI Number	:	1124222104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARL MATTHEW NETTLES JR. MD

Provider Business Mailing Address
First Line	:	1514 JEFFERSON HWY
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70121-2429
Country	:	US
Telephone Number	:	504-842-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	7520 PERKINS RD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-9111
Country	:	US
Telephone Number	:	225-769-6700
Fax Number	:	225-768-7608

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	09/01/2023

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